Medicare Reimbursement Analysis

Good Essays
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is about to turn the way you 're paid by Medicare completely upside down.
Effective Jan. 1, 2017, how you participate with this new program determines whether your future Medicare reimbursement will be increased or decreased. It all depends on the data you submit. And although the data submission requirements are somewhat based on several quality reporting systems you may be familiar with (Physician Quality Reporting System (PQRS), Meaningful Use (MU), Value-Based Modifier (VBM), etc.), don’t be fooled into thinking it’s business as usual. If you don’t follow the new MACRA guidelines carefully, your future income will be reduced by as much as 9%.
MACRA makes three important changes
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Regular APMs incentivize healthcare practitioners to provide high-quality, cost-efficient care for a specific clinical condition, care episode or population, and
2. Advanced APMs let you earn more for taking on a certain level of risk related to your patients’ outcomes. Ultimately, your goal will be to qualify to report your data under an Advanced APM. If you do, you’re exempt from submitting MIPS data, you avoid any future reduction in your Medicare reimbursements, and you’ll receive a guaranteed lump sum payment each year that equals 5% of your last year’s fee-for-service payments. Here’s the catch, there aren’t very many Advanced APMs. That’s the reason the majority of clinicians will report under MIPS the first year. (For more information on Advanced APMs on page
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Unlike for PQRS, you don’t have to register or tell CMS which you plan to do. However, you must pick one, you can’t report some data as a group and some as an individual provider.
NOTE: There will be a registration process if you choose to report Quality measures via the Group Practice Reporting Option (GPRO) website (https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/pqrs/gpro_web_interface.html).

Reporting as a Group
If you report your data as a group, then you’ll generate and submit total numbers for all providers in your group. Your entire group will get one Final Score, and each provider in your group will be assigned that same Final Score and receive the same payment adjustment (either positive or negative). Also, the quality measures you report will be the same for all of your providers.
Generally, larger group practices will select this option because it takes less work than collecting and reviewing data at the individual provider level. Everyone in the group is focused on the same set of measures, and that allows you to develop a single process and workflow to ensure higher scores. This option also permits the group to balance out high-performing and low-performing providers.

Reporting as an Individual

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